KEYNOTE LECTURE
Preparing Healthcare Faculty for the Millennial Generation

INTRODUCTION

If Marshall McLuhan lived long enough to observe the effect of Internet-based communication technology on society and education, even he would be surprised. Technology’s impact on the millennial generation of learners who grew up with the Internet is even greater than the effects of television McLuhan observed, studied and wrote about in the 1960’s and 70’s. The millennial generation, those born between 1984 and 2000 are, more than any prior generation, influenced by new communication technology – text messaging, social networking, wikis, blogs, social media and other Web 2.0 technologies – shape both their approach to life in general and learning specifically.

Here I aim to describe how learning and the teaching healthcare in 2010 and beyond is fundamentally different as a result of technology and its impact on learners changes the role of the modern educator. Recommendations for effectively applying and managing eLearning and Web 2.0 technology are included. I will not attempt to judge whether or not specific technologies have a positive or negative effect on learning but rather, strive to understand how millennial learners are different and how the faculty that teach them might prepare.

Defining the Millennial

Let us begin with an attempt at defining the millennial generation from the perspective of the healthcare educator. This generation does not know a life without the Internet and communication technologies like email and text messaging. Just as McLuhan determined through observation and study that the new technology of the day, television, changed the way people interacted, the effect of Internet technology on the millennials appears even more profound.

“We shape our tools and then our tools shape us.”

Marshall McLuhan (1911-1980)

The defining characteristics of millennials, most worthy of our attention, are communication, collaborating and creating. Millennials more than anything use new technology to communicate. They fully expect to be constantly connected to each other and an entire world of information via convenient technologies. These are primarily text messaging using cell phones and social networking on MySpace, Facebook and newer websites like Orkut and hi5. As one first year medical student told me, “if you’re not on Facebook, you don’t exist.” A recent Pew study reveals that 90% of teenagers sleep with their cell phone in or next to their bed (compared to 65% of adults). To them, personal connection with a worldwide community is a fact of life and not limited by the time and cost barriers of yesteryear’s letter writing and long-distance phone calls.

The unique characteristics of millennials extend beyond their technologies. Neil Howe, in his book “Millennials Rising, The Next Great Generation” reported how millennials describe themselves as “optimists” and “team-players” when surveyed. He also observed that this generation is on track to be the most affluent and the best educated, while at the same time the most diverse with 36% of American millennials being non-white. As the children of the baby-boomers, the last dominant generation, millennials are greater in number and well poised to be the next dominant generation.

Millennials and Their Techonology

At least 97% of millennials own their own computer and 94% have a cell phone based on surveys by Junco and Mastrodicasa. These are staggering numbers when compared to the preceding generation. Other characteristics based their surveys include heavy use of instant messaging (76%) and multitasking (92%). In contrast with their baby-boomer parents, millennials rely primarily on the Internet (34%) and television (40%) as a source of news and current events.1 Print media simply is not consistent with their instant, personalized, on-demand approach to information gathering.

Healthcare Education and Millennials

Inevitably, changes in communication technology impact the classroom. Since the days of Aristotle and Plato, the classroom served as the primary delivery mechanism for sharing of knowledge and the development of intellectual skills. Fast forward more than two thousand years and the classroom still plays a significant role in education. This model, of one teacher co-located with many students in a classroom is still quite efficient for the teacher. This broadcasting approach to teaching was a designed out of necessity but not particularly efficient for the learner. For students who have lived their entire life with handheld, highly distributed, asynchronous communication technologies, the classroom is an archaic communication model. To be tethered to one place, one expert and one cohort of colleagues is simply too limiting when compared to how millennials learn and interact outside the classroom.

Consider the evolution of the “note-taking service” used in medical schools that in my day (1980’s) was revolutionized by inexpensive personal computers used to transcribe recorded lectures and copying machines that replicated the notes that were distributed via mailboxes. Those early days of accessing curricular material outside the classroom evolved to what is now an expectation that school administration record the audio and sometimes video of every lecture and synchronize it with the presentation slides and provide via the Internet within minutes of every lecture. And, provide these lectures to students in multiple digital formats for playback on personal computers, handheld devices and smart phones.

Millennials do not see themselves restricted to a school’s core teaching faculty, textbooks and library. No longer are these the sole source of knowledge, rather Wikipedia, MedScape, online textbooks, UpToDate, and YouTube videos, for better or worse, broaden the medical student’s scope of influence. Spontaneous, unsanctioned websites emerge where students collaborate around study topics, share mnemonics, study guides and quiz each other much as pre-millennials did with in-person study groups. For millennials learning is not restricted to the “class” or the “room.”

Web 2.0 and Education

Web 2.0 is a broad and somewhat ill defined term depending on context and perspective. For our purposes, Web 2.0 refers to web-based technologies (websites, software applications, databases) where the user is the center of attention. User-generated content predominates – YouTube videos, Wikipedia encyclopedic entries, blogs and social networking forums typify this breed of website. They harness collective intelligence and as a result, get better the more people use them. They employ a decentralized, egalitarian approach to content production, editing, and organization. With Web 2.0 everyone with an Internet connection, an inexpensive video camera, and something to say can be “world famous for 15 minutes” validating Andy Warhol’s 1968 prediction of the future.

One of the more popular YouTube video series related to medical education is one created by a first year Harvard medical student who chronicles his trials and tribulations via homemade video broadcasts. Even more surprising than the star’s candor is the degree to which his viewers share their own emotional experiences with each other. These all-digital connections with complete strangers demonstrate how millennials and others do not require face-to-face or real-time contact to interact around deeply personal matters.

What is not to like?

Collaboration, access to seemingly infinite knowledge, personal interaction with individuals worldwide thanks to easy and cheap communication technology – must result in positive effects on learning and training for this next generation of healthcare professionals, right? Recently a few cognitive scientists and sociologists have raised a cautionary flag.

Nicholas Carr, in his provocative article “Is Google Making Us Stupid” aggregates data from various cognitive science and sociology studies suggesting that instant access to vast amounts of information via Google and other search engines may be negatively affecting our ability to focus and learn deeply.2 Informal interviews with both baby boomers and their progeny the “echo-boomers,” raises concerns that we all may be losing our ability to concentrate on a single subject for an extended period of time. Web technologies favor speed and quick answers over in-depth analysis of complex subjects. As one observer put it, “Internet knowledge a mile wide and a half an inch deep.”

A few years ago I began referring to students and trainees as the “cut and paste” generation after noticing that some had a habit of cutting excerpts from Wikipedia, MedScape and elsewhere in electronic medical record and pasting them into their own electronic reports verbatim. More disturbing was that these reports lacked any original thought and analysis, or even paraphrasing. Obviously this habit can have negative effects on the traditional clinical education model. Recently our academic medical center had to institute a formal “cut and paste policy” to restrict mindless replication within the electronic medical record.

What is an educator to do?

Some may interpret improved access to knowledge and information and the decentralization of content production and organization as threats to the value of teachers. To the contrary, educators are needed more than ever. Bloom’s taxonomy of cognitive skills provides the theoretical framework demonstrating a hierarchy necessary to reach expertise. At the bottom of his taxonomy is Knowledge, then he steps up a pyramid with progressively higher skill levels of Comprehension, Application, Analysis, Synthesis and finally Evaluation as one strives for expertise. Millennials’ Internet tools and information resources vastly expand access to the bottom level of the taxonomy, knowledge. Some sophisticated eLearning and web-based educational programs may help learners with comprehension, but very few target higher-level cognitive skills. Acquiring the ability to apply knowledge to real-world problems, analyze complex data, synthesize new solutions and evaluate problem-solving and decision-making still require interaction between learner and teacher.

A new job description is emerging for the teaching faculty of the millennial generation. To adapt, modern educators’ skill set should extend to things like 1) digital knowledge skills, 2) applying interactive eLearning tools to teach higher cognitive skills, and 3) instilling the motivation in learners to think critically, learn deeply and seek novel answers.

Digital knowledge skills

Easy access to large amounts of ever-changing medical knowledge means that educators can shift some of the time and energy previously spent distributing knowledge (lectures, textbooks) and dedicate more teaching time to how to efficiently manage digital knowledge resources and apply knowledge using advanced cognitive skills (simulation, team-based learning, project-based learning). More than ever, students still need teachers to help them comprehend knowledge, apply it and know when and how to act on it.

Efficient use of databases of indexed, peer-reviewed research data like that contained in Medline requires a different skill set than searching Google and using encyclopedic community knowledge found in Wikipedia. Students need to understand the underlying data structures, how the different search engines work along with the advantages and disadvantages of the search results from each.

eLearning for comprehension, application, analysis, and synthesis

Educators of the millennial generation can spend more time teaching them how to use digital information and knowledge to solve problems, reach new levels of understanding and discover innovative approaches to research and healthcare. eLearning tools and Web 2.0 technologies are familiar to millennial learners and can assist in acquiring these cognitive skills.

For example, comprehension can be assessed with simple question and answer sessions in small groups, possibly focused around a real or simulated clinical case study. Online quizzes and virtual patients (computer-based clinical simulations) are used for formative evaluation allowing the student and teacher to recognize areas of deficiency and move on to the next topic when competency is demonstrated.

A specific example of Web 2.0 technology used to formatively assess competency is what our faculty call “Course Director Blogs.” Each course director has his or her own dedicated web page where he or she posts daily reflections on the course and students submit questions and comments for all to see. Another is the University of Vermont’s student-run wiki where they collaboratively organize the course materials and contribute user-generated study guides and links to resources that supplement the core curriculum.

At the University of Pittsburgh we teach students to critically analyze and apply knowledge from the medical literature as part of a longitudinal individual scholarly project. Students electronically select their own research or academic project, find a mentor, develop a proposal for peer-review and when approved, collaboratively pursue their academic project both online and offline. Higher-level cognitive skills are acquired in the course of completing their mentored scholarly project by setting specific goals and deliverables.³

While first generation eLearning tools were shown to be similar in effectiveness when applied to traditional learning tasks such as knowledge transfer, when used to teach higher-order cognitive skills such as analysis and application, some active eLearning programs exceed traditional methods.⁴ Virtual patients (computer-based clinical simulations) are a good example of how digital learning applications can teach things like clinical reasoning, a skill that is otherwise difficult to teach in the classroom or with traditional linear text-based instruction.^5,6 Also, computer animation has been shown effective for teaching complex procedural and motor skills.⁷ A recent literature review concluded that when eLearning provides adaptive, personalized feedback it could outperform conventional methods.⁸ These are the approaches to teaching that an always-connected, digitally savvy millennial student expects from a modern faculty member.

Motivation to think critically, learn deeply and seek new answers

The role of the modern educator extends beyond imparting knowledge and skills to instilling positive motivating attitudes in millennial learners. Despite advances in technology, learning is still hard. As in the past, teachers need to inspire and motivate learners to seek out the best knowledge, higher understanding and achieve unique solutions. Access to quick, superficial answers may make this part of a faculty’s job harder than ever. More than ever, educators need to motivate students to learn deeply and develop the necessary critical reasoning skills to become life-long learners. This can be accomplished through personalized feedback, individual mentoring, and demonstrating how expertise leads to improved clinical outcomes. As in the past, the educator must serve as a role model for the millennial generation.

CONCLUSIONS

Millennial generation students are different – in large part due to the communication technologies that shape their everyday lives. The Internet, text messaging, social networking and social media, offer both advantages and disadvantages to the learner and teacher. Despite easy access to vast digital knowledge and availability of eLearning technologies like simulation and adaptive learning, the road to expertise is still a hard one. By understanding the unique characteristics and needs of millennial learners and embracing the valuable aspects of the technologies they know so well, modern educators can help them become the next great generation of healthcare professionals.

REFERENCES

1. Junco R, Mastrodicasa J (2007). Connecting to the Net Generation: What Higher Education Professionals Need to Know about Today’s Students. Washington DC. National Association of Student Personnel Administrators.
2. Carr N (2008). Is Google making us stupid? Atlantic Monthly July/August 2008.
3. Boninger M, Troen P, Green E, Borkan J, Lance-Jones C, Humphrey A, Gruppuso P, Kant P, McGee J, Willochell M, Schor N, Kanter SL, Levine AS (2010). Implementation of a Longitudinal Mentored Scholarly Project: An Approach at Two Medical Schools. Academic Medicine, 85;429-437.
4. Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, & Montori VM (2008). Internet-based learning in the health professions. Journal of the American Medical Association 300, 1181-1196.
5. Cook DA, Triola MM (2009). Virtual patients: A critical literature review and proposed next steps. medical Education 43, 303-311.
6. Gesundheit N, Brutlag P, Youngblood P, Gunning WT, Zary N, Fors U (2009). The use of virtual patients to assess the clinical skills and reasoning of medical students: initial insights on student acceptance. Medical Teacher, 31:739-742.
7. Ruiz JG, Cook DA, Levinson AJ (2009). Computer animations in medical education: a critical literature review. Medical Education 43(9), 838-46.
8. Cook DA, Erwin PJ, Triola MM (2010). Computerized virtual patient in health professions education: A systematic review and meta-analysis. Academic Medicine 85, Epub ahead of print.